Lab Considerations : Ebola

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1 1 Lab Considerations : Ebola Ebola testing Public Health approval HCW safety Type of tests Specimens Permits Packaging Testing during treatment In-house Reference lab Point of care Lab Waste Disinfection 2 1

Interim Guidance for U.S. Hospital Preparedness for Patients with Possible or Confirmed Ebola Virus Disease: A Framework for a Tiered Approach http://www.

html Dec 2, 2014 3 Guidance/Recommendations for a Frontline HCF Ebola testing at nearest Laboratory Response Network lab (LRN) in accordance with the

2 Interim Guidance for U.S. Hospital Preparedness for Patients with Possible or Confirmed Ebola Virus Disease: A Framework for a Tiered Approach Dec 2, Guidance/Recommendations for a Frontline HCF Ebola testing at nearest Laboratory Response Network lab (LRN) in accordance with the state s plan Frontline facility not expected to provide prolonged care (>12 24 hrs) for severely ill patient. Ensure there is no care delay for patients by being prepared to test, manage, and treat alternative etiologies (e.g., malaria in travelers) when indicated. 4 2

Laboratory Response Network LRN Ebola testing lab In order to qualify, a laboratory must have: appropriate, functioning biosafety level 3 lab the necessary test reagents needed PPE to

3 Laboratory Response Network LRN Ebola testing lab In order to qualify, a laboratory must have: appropriate, functioning biosafety level 3 lab the necessary test reagents needed PPE to perform the assay safely A testing lab demonstrates competency by successful completion of a quality assurance panel. 5 Laboratory Response Network (LRN) Ebola Testing Laboratories 6 3

4 Patient presents with Ebola travel history In the early stages, Ebola can be hard to distinguish from other diseases like malaria, typhoid fever, and meningitis Specimens from patients with active Ebola disease are hazardous Special laboratory precautions and procedures are needed for safe transportation and handling From: Top Questions About Ebola 2014 Association of State and Territorial Health Officials 7 Patient with Ebola travel history to test or not to test Existing blood tests are designed to confirm a suspicion of Ebola Person must have Ebola symptoms at time of blood draw Screening prior to symptoms not helpful as the tests will not detect the virus during incubation period Using the existing Ebola tests to evaluate blood from people who do not have symptoms would cause mistakes. Existing Ebola tests require special lab procedures and equipment FDA Emergency Use Authorization (EUA) for new Ebola tests Local and state labs : testing complete within hours From: Top Questions About Ebola 2014 Association of State and Territorial Health Officials 8 4

Ebola 101 for Healthcare Professionals ( 32 slide ppt) http://www.cdc.

5 Ebola 101 for Healthcare Professionals ( 32 slide ppt) Lag in PCR positivity: virus in blood specimens Antibody response: IgM and IgG serology 9 Standard Ebola Testing (CDC guidance) Real Time PCR (RT-PCR) Test Diagnose acute infection More sensitive than antigen test (e.g. ELISA) Identifies select viral genetic fragments RT-PCR Samples Four (4) ml whole blood Plastic collection tubes (not glass or heparinized tubes) EDTA tube (whole blood) preferred Whole blood preserved with sodium polyanethol sulfonate (SPS), citrate, or with clot activator is acceptable Standard testing = blood only (other specimens not necessary, only on consultation with CDC) 10 5

Testing for Ebola Patient with risk history/factors, no symptoms Ebola testing not indicated No restriction for non-ebola testing Refrain from donating blood during 21 day incubation period Patient

testing timeframe established o Obtain specimen - CDC designated testing NO SPECIMENS WILL BE TESTED FOR EBOLA WITHOUT HEALTH DEPARTMENT CONSULTATION 11 Interpreting Negative Ebola RT-PCR Result If

6 Testing for Ebola Patient with risk history/factors, no symptoms Ebola testing not indicated No restriction for non-ebola testing Refrain from donating blood during 21 day incubation period Patient with risk history/factors AND symptoms All necessary precautions Prior to obtaining any specimens, contact health department o Person Under Investigation (PUI) determination is made o Appropriate testing timeframe established o Obtain specimen - CDC designated testing NO SPECIMENS WILL BE TESTED FOR EBOLA WITHOUT HEALTH DEPARTMENT CONSULTATION 11 Interpreting Negative Ebola RT-PCR Result If symptoms started 3 days before the negative result EVD is unlikely consider other diagnoses Infection control precautions for EVD can be discontinued unless clinical suspicion for EVD persists If symptoms started <3 days before the negative RT-PCR result Interpret result with caution Repeat the test at 72 hours after onset of symptoms Keep in isolation as a suspected case until a repeat RT-PCR 72 hours after onset of symptoms is negative 12 6

7 CDC Interim Guidance Specimen Collection, Transport, Testing and Submission Ebola 101 for Healthcare Professionals CDC : PowerPoint Slides for U.S. Healthcare Workers November 21, 2014 on CDC webpage 13 Specimen Collection Phlebotomy by HCW in PPE as appropriate per patient assessment i.e. same PPE as caregiver (nurse, doctor) Gloves, water-resistant gowns, full face shield or goggles, and masks to cover all of nose and mouth. Additional PPE may be required in certain situations. Consider delegating specimen collection to patient s care provider (minimize number of HCWs providing care) Disinfect outer part of blood tubes, drop into biohazard specimen bag, seal bag Place specimens in a durable, leak-proof secondary container for careful transport of specimen to lab. Do not use pneumatic tube system 14 7

8 Specimen Processing Full Ebola PPE protocols, including trained doffing and donning, apply when in the patient care area. Lab staff who receive and package specimens in the laboratory should wear appropriate clinical laboratory PPE (e.g. gloves, mask, face shield, impermeable gown) Specimen Processing and Testing Laboratory Ebola Preparedness As appropriate, work in containment environment, i.e. one engineered to control risk of exposure o work in a class II Biosafety cabinet, or o work behind a Plexiglass splash guard Risk Assessment of relevant manual and automated processes regarding risk of aerosolization and splash during testing Any manual or automated process in which aerosolization and splashing cannot be controlled/eliminated is not to be used Documented training and competency 16 8

9 Laboratory Findings : Symptomatic Ebola Thrombocytopenia (50, ,000/L range) Leukopenia followed by neutrophilia Transaminase elevation: elevation serum aspartate aminotransferase (AST) > alanine transferase (ALT) Electrolyte abnormalities from fluid shifts Coagulation: PT and PTT prolonged Renal: proteinuria, increased creatinine 17 Initial Lab Tests Clinical Assessment Malaria test Influenza Group A Strep CBC Liver Function Tests Coagulation tests Electrolytes Renal Function Tests Cultures - see guidance from ASM For confirmed Ebola, preferred lab response is point of care (POC) and rapid methods in satellite lab inside or near patient isolation room. Verify that all lab instrument manufacturer-installed safety features are in place and functional 18 9

10 Special considerations Ebola virus is regulated as select Tier 1 agent per HHS Select Agent regulations (42 CFR Part 73): Tier 1 subset presents greatest risk for deliberate misuse with significant potential for mass casualties or devastating effect to the economy, critical infrastructure, or public confidence; poses a severe threat to public health and safety Persons Under Investigation (PUI) specimens to be managed as Tier 1 agent if confirmed to be Ebola 19 Can you ship the specimen? Ebola virus is classified as a Category A infectious substance by the Department of Transportation (DOT) Contact state and/or local health department* to determine the proper category for shipment (per clinical history and risk assessment) *State guidelines may differ and state or local health departments should be consulted prior to shipping. NO specimens will be accepted without prior consultation with appropriate health authorities. (Additional consultation CDC Emergency Operations Center (EOC) at )

11 Can you ship the specimen? FedEx may accept PUI delivery to public health lab FedEx will not accept proven ( by molecular or other confirmatory test) Ebola positive patient specimen arrange for courier who accepts risk group 4 in Category A package oworld Courier is an example commercial courier service currently accepting known Ebola samples oprivate Courier may transport Category A substances if they are appropriately trained and able to transport a select agent (if known to be Ebola) 21 Blood specimens for Ebola Diagnosis Store and transport at correct temperature o 2-8 C or frozen on cold-packs Standard label on each specimen tube Do not centrifuge specimen Do not open or manipulate specimen (pipette, pouroff, split) Fill out CDC specimen form: CDC test directory code CDC Ebola Identification 22 11

12 Specimen Collection and Processing: Packaging and Shipping Category A Samples Obtain special packaging prior to needing it! basic triple packaging system : primary container (sealable specimen bag) wrapped with absorbent material secondary container (watertight, leak-proof) an outer shipping package Train* lab personnel on packaging and shipping Category A samples per Ebola (and bioterrorism) preparedness *shippers (e.g labs) must have trained staff with documented shipping training (USDOT and USPS Regulations for Packaging and Labeling Infectious Substances) %20Safely.pdf 23 Lab staff training and competency: Category A Laboratory is responsible for certifying staff in packaging and shipping: Keeps training records on packaging and shipping general awareness function specific safety security awareness, and in-depth security training Provides documentation on competency in each area of training required for packaging and shipping certification. Retrains and assesses competency, documented every 2 years and whenever changes to the regulations occur

13 Packaging & Shipping Clinical Specimens to CDC for Ebola Testing 25 Waste generated during laboratory testing Lab waste captured in leak-proof containment To minimize contamination of the exterior of waste bag, place in a rigid waste container Lab waste from confirmed Ebola patient requires special treatment (e.g. incineration) Collaborate with facility waste handler For equipment that drains directly into the sewer system, the U.S. sanitary sewer system handling processes (e.g., anaerobic digestion, composting, disinfection) will safely inactivate infectious agents. However, check with your state's medical waste program for more guidance 13

14 Disinfection EPA-registered disinfectants Disinfectant must have claim for at least one of the common nonenveloped viruses (e.g., norovirus, rotavirus, adenovirus, poliovirus) Lab instruments capable of safely testing specimens with bloodborne pathogens However, check with manufacturer regarding warranty issues, maintenance, service calls if used for Ebola confirmed specimens Consider ramifications of a blood spill or lab accident when making decisions to test in main lab ASM suggested practices: Specimen Processing Specimen removal from patient s room and transport of samples to laboratory should be kept to a minimum Specimen processing may be performed in any of the following: in the patient s room nearby in a contained testing area inside a biological safety cabinet in negative pressure room inside a BSC in an isolated area of the laboratory Interim Laboratory Guidelines for Handling/Testing Specimens from Cases or Suspected Cases of Hemorrhagic Fever Virus (HFV) American Society for Microbiology (ASM) September 10, 2014 (2nd version*) 28 14

15 Main Resources Interim Guidance for U.S. Hospital Preparedness for Patients with Possible or Confirmed Ebola Virus Disease: A Framework for a Tiered Approach CDC Interim Guidance Specimen Collection, Transport, Testing and Submission Ebola 101 for Healthcare Professionals CDC PowerPoint Slides for U.S. Healthcare Workers November 21, 2014 (found on CDC webpage) Top Questions About Ebola 2014 Association of State and Territorial Health Officials Interim Laboratory Guidelines for Handling/Testing Specimens from Cases or Suspected Cases of Hemorrhagic Fever Virus (HFV) American Society for Microbiology (ASM) September 10, 2014 (2nd version*) PHL Guidance for Clinical Laboratories Using FDA Authorized Diagnostic Assays for Ebola Zaire Virus Detection (see above). Developed a template to assist laboratories in conducting risk assessments of their facilities. Interim Laboratory Guidelines for Handling/Testing Specimens from Cases or Suspected Cases of Hemorrhagic Fever Virus (HFV) American Society for Microbiology (ASM) September 10, 2014 (2nd version*) ASM agrees with the CDC that all laboratory testing must follow standard precautions In addition, ASM has developed enhanced precautions HCF labs may choose to adopt these in an abundance of caution as one possible approach to testing safety As always, contact your State Health Laboratory regarding Ebola Testing and submission of specimens to the CDC

PPE Selection Matrix for Occupational Exposure to Ebola... https://www.

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16 PPE Selection Matrix for Occupational Exposure to Ebola... Safety and Health Administration to Ebola virus and that workers are not exposed to harmful levels of chemicals used for... OSHA PPE Selection Matrix for Occupational Exposure to Ebola Virus

1. Guidance from the CDC. 2. Acquired knowledge of the biological characteristics of enveloped viruses.

1. Guidance from the CDC. 2. Acquired knowledge of the biological characteristics of enveloped viruses. Introduction October 24, 2014 As reported by the Centers for Disease Control and Prevention (CDC), the 2014 Ebola epidemic is the largest in history, affecting multiple countries in West Africa. In the